REVIEW CLINICIAN’S CORNER

Prenatal and Postpartum Depression in Fathers

and Its Association With Maternal Depression
A Meta-analysis
James F. Paulson, PhD Context It is well established that maternal prenatal and postpartum depression is
Sharnail D. Bazemore, MS prevalent and has negative personal, family, and child developmental outcomes. Pa-
ternal depression during this period may have similar characteristics, but data are based

T
HE PREVALENCE , RISK FAC -
tors, and effects of depression
among new fathers are poorly
understood. Although a large
body of research on maternal depres-
sion documents incidence rates be-
tween 10% and 30% and negative
family and child developmental out-
comes,1-3 paternal prenatal and post-
partum depression has received little at-
tention from researchers and clinicians.4
The emerging literature on paternal de-
pression suggests that, like their ma-
ternal counterparts, fathers are at in-
creased risk of depression in the
postpartum 5 and gestational peri-
ods.6-8 Moreover, several studies have
now documented negative child out-
comes associated with paternal prena-
tal and postpartum depression.9,10
Although recent literature has ad-
dressed this phenomenon, studies in pa-
ternal prenatal and postpartum depres-
sion are troubled by inconsistent
methods, clinical heterogeneity, and
prevalence estimates that vary consid-
erably.5,7,11-20 To date, only 2 reviews on
prenatal and postpartum depression in
on an emerging and currently inconsistent literature.
Objective To describe point estimates and variability in rates of paternal prenatal
and postpartum depression over time and its association with maternal depression.
Data Sources Studies that documented depression in fathers between the first tri-
mester and the first postpartum year were identified through MEDLINE, PsycINFO,
EMBASE, Google Scholar, dissertation abstracts, and reference lists for the period be-
tween January 1980 and October 2009.
Study Selection Studies that reported identified cases within the selected time frame
were included, yielding a total of 43 studies involving 28 004 participants after dupli-
cate reports and data were excluded.
Data Extraction Information on rates of paternal and maternal depression, as well
as reported paternal-maternal depressive correlations, was extracted independently
by 2 raters. Effect sizes were calculated using logits, which were back-transformed and
reported as proportions. Random-effects models of event rates were used because of
significant heterogeneity. Moderator analyses included timing, measurement method,
and study location. Study quality ratings were calculated and used for sensitivity analy-
sis. Publication bias was evaluated with funnel plots and the Egger method.
Data Synthesis Substantial heterogeneity was observed among rates of paternal
depression, with a meta-estimate of 10.4% (95% confidence interval [CI], 8.5%-
12.7%). Higher rates of depression were reported during the 3- to 6-month postpar-
tum period (25.6%; 95% CI, 17.3%-36.1%). The correlation between paternal and
maternal depression was positive and moderate in size (r = 0.308; 95% CI, 0.228-
0.384). No evidence of significant publication bias was detected.
Conclusions Prenatal and postpartum depression was evident in about 10% of men
in the reviewed studies and was relatively higher in the 3- to 6-month postpartum
period. Paternal depression also showed a moderate positive correlation with mater-
nal depression.
JAMA. 2010;303(19):1961-1969 www.jama.com

fathers have been published, but nei-

ther sought to quantitatively synthe-
size or resolve the discrepancies across
studies, methods, or other issues.5,11 We
conducted the present meta-analysis of
CME available online at
www.jamaarchivescme.com
and questions on p 1987.
depression in expecting and new fa-
thers to (1) estimate paternal depres-
sion between the first trimester and 1
year postpartum; (2) describe differ-
ences across time within this period; (3)
examine the association between pa-
ternal and maternal depression; (4) es-
timate the prevalence of maternal pre-
natal and postpartum depression
identified in paternal depression stud-
ies; and (5) identify how published rates
Author Affiliations: Department of Pediatrics, East-
ern Virginia Medical School, Norfolk.
Corresponding Author: James F. Paulson, PhD, De-
partment of Pediatrics, Eastern Virginia Medical School,
E. V. Williams Hall, 855 W Brambleton Ave, Norfolk,
VA 23510 (paulsojf@evms.edu).

©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1961

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 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS
of paternal depression were affected by
methodological factors such as mea-
surement method, study location, and
sample risk status.
METHODS
Search Strategy
We used 3 methods to identify studies
for this meta-analysis. First, we used the
reference lists of the most relevant re-
views.5,11 Next, we searched MEDLINE,
PsycINFO, Dissertation Abstracts In-
ternational, EMBASE, and Google
Scholar using the search terms depres-
sion, paternal, father, postnatal, postpar-
tum, prenatal, antenatal, and perinatal.
Finally, we used the “ancestry ap-
proach,”21 which involves consulting
the reference lists of retrieved articles
to find earlier relevant studies. Be-
cause of the emergent nature of this
body of observational research litera-
ture, an inclusive approach to study se-
lection was used.22,23 Therefore, we in-
cluded all relevant and accessible
journal articles, dissertations, and book
chapters that were produced between
January 1980 and October 2009 that as-
sessed paternal depression during preg-
nancy, the first postpartum year, or
both.
Study Selection
Studies that reported an estimated
number of depression cases among
identified fathers were included. This
resulted in the exclusion of several
studies that reported mean scores for
symptom severity because the exact
number of cases could not be clearly de-
termined. Several articles9,10,24-27 used
data from common databases and were
excluded to avoid duplication of data.
Several studies measured depression on
multiple occasions. In these cases, 1
depression measure per time period
was selected based on these priorities:
(1) structured interviews; (2) mea-
sures with demonstrated generality in
men (eg, Beck Depression Inven-
tory28) vs adaptations of maternal mea-
sures (eg, Edinburgh Postnatal Depres-
sion Scale29); and (3) measures with
greater specificity for depression (eg,
Beck Depression Inventory28 vs Gen-
1962 JAMA, May 19, 2010—Vol 303, No. 19 (Reprinted)
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eral Health Questionnaire30). We ex-
cluded studies that selected fathers
based on established maternal mental
health problems because this could bias
meta-analytic estimates. Also, because
the identified studies of teen fathers
were characterized by significant eco-
nomic and social stressors, only stud-
ies of fathers aged 18 years or older were
included.
Data Abstraction
and Quality Assessment
The 2 authors used a standardized cod-
ing manual (available from the au-
thors on request) to extract the follow-
ing data from articles: author names,
publication year, sample size, period of
assessment, study sample risk (0 or 1;
high risk coded when a study denoted
this clearly, including medically as-
sisted pregnancies and infants with
feeding, sleeping, or crying prob-
lems), location, sample size, response
rate, number of fathers identified as de-
pressed, number of mothers identified
as depressed (when assessed), and cor-
relation between maternal and pater-
nal depressive symptoms. The coding
manual was developed a priori and
modified after use in several studies.
Coding was done independently then
aggregated, with disagreements re-
solved through discussion and con-
sensus. Although quality assessment
can be reliably conducted in meta-
analyses of experimental studies, its use
in observational research is controver-
sial, with no clear consensus on rating
methods or their appropriate use in
analysis. As such, we used a simple ob-
jective rating system (based on the
meta-analysis of similar data by Ben-
nett et al2) that coded studies on a scale
of 0 to 10, assigning 2 points each for
sampling method (systematic or prob-
ability vs convenience or not re-
ported), presence of clearly stated in-
clusion criteria, racial/ethnic diversity
(ⱖ20% minority), educational diver-
sity (ⱕ80% at 1 educational level), and
response rate (reported at ⱖ60%). Stud-
ies that did not report these method-
ological issues received lower scores.
Because evidence on the validity of
©2010 American Medical Association. All rights reserved.
quality ratings in observational re-
search is lacking, we adopted the ap-
proach of Stroup et al23 of broadly in-
cluding studies and using sensitivity
analysis to determine incremental ef-
fects of lower-quality studies.
Effect Size and Statistical Analysis
Primary Outcome. The primary out-
come was the point prevalence rate of
paternal depression, defined as the
number of cases divided by the total
number of study participants. We coded
these into both simple proportional
effect sizes (by dividing the number of
cases by the sample size) and logit units,
as a direct transformation of these pro-
portions. In this context, the logit trans-
formation was used to form an un-
bounded (in contrast to the 0-to-1
bounded nature of proportions) esti-
mate to facilitate moderator analy-
sis.31 After analysis, logit units were
back-transformed to proportions for the
purposes of reporting.
Secondary Outcomes. Secondary
outcomes included rates of depres-
sion in female partners, which we coded
as raw proportions and logit units, and
standardized zero-order correlations be-
tween paternal and maternal depres-
sive symptoms (when measured with
a continuous or ordinal scale).
All major analyses were conducted
with Comprehensive Meta-Analysis,
version 2.0. 32 In general, random-
effects models are argued to better ad-
dress heterogeneity between studies and
study populations, allowing for greater
flexibility in parsing effect size variabil-
ity. Moreover, they are less influenced
by extreme variations in sample size.22
Because studies in this meta-analysis are
characterized by heterogeneity and
highly variable sample sizes, random-
effects models were used. Heteroge-
neity among study point estimates was
assessed with the Q statistic, with mag-
nitude of heterogeneity being evalu-
ated with the I 2 index. 31 When re-
ported, all confidence intervals (CIs)
reflect a 95% criterion.
We examined the following deter-
minants of primary and secondary out-
comes: period of measurement, risk sta-

tus of the sample (eg, infant problems,
medically assisted fertilization), and
case identification method (interview
vs rating scale). Study location was also
coded because previous work has iden-
tified geographic variations in postpar-
tum depression.33 Because the timing
of paternal depression vis-à-vis child-
birth is of great interest in this study,
period of measurement was coded into
blocks that included (1) first trimester
to 6 months’ gestation, (2) greater than
6 months’ gestation to birth, (3) im-
mediately postbirth to 3 months post-
partum, (4) greater than 3 months post-
partum to 6 months postpartum, and
(5) greater than 6 months postpartum
to 12 months postpartum.
Publication bias was assessed by vi-
sually inspecting funnel plots and ap-
plying the regression intercept of
Egger et al.34 In addition, we used the
fail-safe procedure of Orwin,35 which
is based on effect sizes that would be
considered practically insignificant
rather than the traditional null-effect
reference. This generated a number of
unpublished studies with effects at the
estimated population base rate for adult
male depression36 that would be needed
to move estimates to a nonsignificant
difference from base rates.
To assess the robustness of the re-
sults, we performed sensitivity analy-
ses by sequentially removing each study
and rerunning the analysis. We also
conducted a separate analysis exclud-
ing studies with quality ratings in the
lowest third to determine if potential
methodological weaknesses influ-
enced meta-analytic estimates.
RESULTS
Included Studies
Of the initial 256 identified studies,
most (n=163) were excluded because
they were not applicable to the pres-
ent meta-analysis (eg, articles on other
topics, depression not assessed in fa-
thers, reviews or summaries, beyond
postpartum period, infant death, teen
parents). Of those that were reviewed
in full text, 30 were excluded because
the proportion of depressive cases was
not reported, 16 reported on a sample
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PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS
Figure 1. Study Selection for Inclusion in Meta-analysis
489 Potentially relevant studies identified
233 Duplicates excluded
256 Potentially eligible studies identified
208 Published articles (MEDLINE,
EMBASE, PsycINFO, Google Scholar)
43 Dissertations (Dissertation Abstracts
International, PsycINFO)
5 Books or book chapters (MEDLINE,
EMBASE, PsycINFO, Google Scholar)
163 Excluded based on title/abstract review
99 Depression not assessed in fathers (mothers only)
26 Reviews/reports/summaries, etc
21 Topic not related to meta-analysis
6 Depression assessed beyond postpartum period
4 Depression assessed in fathers who experienced loss
of infant
4 Sample fathers recruited only after partners were
identified as depressed
3 Depression assessed in teen parents
93 Retrieved for full-text review
50 Excluded
30 Proportion of depressed fathers not reported
16 Duplicate samples
4 Irretrievable
2 Unavailable in English
2 Unable to obtain
43 Articles included in meta-analysis
already included in the present study, based sampling procedures embedded
and 4 were not retrievable (FIGURE 1). within larger birth cohort studies, but
After a thorough review, 43 studies met most studies (n=30) recruited from ma-
the inclusion criteria for this meta- ternity or postpartum units, the re-
analysis6-8,13-20,37-68 (TABLE). Of these mainder coming from parenting/
studies, 23 reported rates of paternal de- prenatal classes and other health
pression at 2 or more time points and services. Thirty studies reported re-
20 reported a single observation. Be- sponse rates greater than 70%. In ad-
cause the inclusion of multiple effect dition to reporting paternal depres-
sizes from a single sample would com- sion, 35 studies reported rates of
promise the independence assump- partners’ maternal depression and 14
tion of meta-analysis,22 primary analy- reported the correlation between ma-
ses used the earliest reported estimate, ternal and paternal depressive symp-
as this generally reflects a larger preat- toms. Sample sizes varied widely across
trition sample size. studies (N = 23-10 975), with a me-
The Table provides details on the dian of 130 participants (first quar-
characteristics of the 43 studies. Stud- tile = 80; third quartile = 307). In all,
ies originated in 16 countries, with the using initial sample sizes across the 43
United States contributing the most studies, a total of 28 004 participants are
(n = 17 studies). Most studies (n=40) represented in this meta-analysis.
used a self-report rating scale as the pri-
mary case definition method, with the Tests for Heterogeneity
remainder (n=3) using a structured or According to the criteria set by Hig-
semistructured interview. Three stud- gins and Thompson,69 the heteroge-
ies enrolled men from higher-risk neity in published rates of paternal de-
samples. Two studies used population- pression was statistically significant and
(Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1963
 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS

large in magnitude (Q = 825.081;

Table. Characteristics of Studies Included in Meta-analysis
P⬍.001; I2 =94.910; ␶2 =0.470). Mater-
Depressed, No. (%) Correlation
Depression No. of Between nal depression also demonstrated sig-
Source (Study Location) Measure Participants Men and
and Time of Assessment (Cutoff ) (Women) a Men Women Womenb
nificant heterogeneity across studies
Onset of paternal depression at gestation ⬍6 mo (Q = 1394.968; P ⬍ .001; I2 = 97.563;
Areias et al,17 1996 (Portugal) SADS ␶2 =0.792), but the evidence for hetero-
6 mo gestation 42 (54) 2 (4.8) 9 (16.7) geneity among correlations between
3 mo postpartum 12 (24) 2 (8.3) 17 (67)
maternal and paternal depressive symp-
12 mo postpartum 42 (54) 10 (23.8) 20 (37)
Condon et al,6 2004 (Australia)
toms was equivocal (Q = 89.906;
5.75 mo gestation EPDS (⬎12) 312 16 (5.2) P⬍ .001; I2 =85.540; ␶2 =0.019).
GHQ (⬎5) 57 (18.2)
MHI-5 (⬍17) 14 (4.6) Primary Outcomes
3 mo postpartum EPDS (⬎12) 276 5 (1.9)
The overall random-effects estimate of
GHQ (⬎5) 31 (11.3)
MHI-5 (⬍17) 4 (1.5)
paternal depression was 10.4% (95% CI,
6 mo postpartum EPDS (⬎12) 241 5 (2.1) 8.5%-12.7%) (FIGURE 2). Although no
GHQ (⬎5) 27 (11.2) significant differences in depression
MHI-5 (⬍17) 4 (1.7) rates were observed between higher-
12 mo postpartum EPDS (⬎12) 222 5 (2.3) and lower-risk samples (lower risk,
GHQ (⬎5) 23 (10.4)
10.1%; 95% CI, 8.2%-12.4%; higher
MHI-5 (⬍17) 7 (3.1)
Fawcett and York,14 1986 (US) BDI (⬎9)
risk, 15.6%; 95% CI, 5.6%-36.5%;
3.5 mo gestation 23 1 (4.3) 6 (26.1) Q=0.721; P =.40), moderator analyses
9 mo gestation 24 2 (8.3) 8 (33.3) revealed 3 significant factors. First, there
1.5 mo postpartum 23 3 (13) 6 (26.1) was considerable variability between
Field et al,43 2006 (US) different time periods vis-à-vis birth
5 mo gestation CES-D (⬎15) 156 50 (32) 56 (36)
(Q = 20.256; P ⬍ .001), with the 3- to
Fletcher et al,44 2008 (Australia)
Sometime during gestation EPDS (⬎9) 307 16 (5.3)
6-month postpartum period showing
EPDS (⬎6) 307 48 (15.5) the highest rate (25.6%; 95% CI, 17.3%-
Frost,45 1996 (US) CES-D (⬎15) 36.1%) and the first 3 postpartum
5 mo gestation 527 75 (14.2) 353 (67) 0.23 months showing the lowest rate (19
1 mo postpartum 476 67 (14) 100 (21) 0.16 studies; 7.7%; 95% CI, 5.3%-11.1%).
4 mo postpartum 442 46 (10.6) 93 (21) 0.17
Second, national origin of the study ac-
Matthey et al,20 2000 (Australia) Multiple
measures counted for variability in depression
used to rates of fathers (Q = 7.108; P = .008),
designate
cases c with the US studies reporting an aver-
5.5 mo gestation 152 8 (5.3) 19 (12.3) 0.18 age rate of 14.1% (95% CI, 10.9%-
1.5 mo postpartum 141 4 (2.8) 11 (7.7) 0.22 18.0%) and international studies re-
4 mo postpartum 125 4 (3.2) 12 (9.7) 0.18
porting an average rate of 8.2% (95%
12 mo postpartum 128 6 (4.7) 16 (12.4) 0.32
Ramchandani et al,55 2008 (UK) EPDS (⬎12) 10 975 0.26-0.31
CI, 5.9%-11.1%). Finally, interview-
4.5 mo gestation 426 (3.9) based case definition methods were as-
2 mo postpartum 399 (3.6) sociated with lower overall preva-
8 mo postpartum 378 (3.4) lence estimates (rating scale, 11.0%;
21 mo postpartum 425 (3.9) 95% CI, 8.9%-13.5%; interview, 4.9%;
van den Berg et al,7 2009
(the Netherlands) 95% CI, 3.6%-6.7%; Q = 18.236;
4 mo gestation BSI (⬎15) 3083 (3822) 364 (11.8) 409 (10.7) P ⬍ .001). Because paternal age and
Onset of paternal depression at gestation 6-9 mo family size were inconsistently re-
Atkinson and Rickel,37 1984 (US) BDI (⬎9) 78
8 mo gestation 10 (13) 23 (29)
ported, conclusions could not be drawn
2 mo postpartum 10 (13) 20 (26) regarding the moderator effects of
Bourne,60 2006 (US) CES-D (⬎8) either.
8 mo gestation 120 17 (14) 48 (40) 0.17 Maternal depression had a meta-
12 mo postpartum 87 8 (9) 23 (27) 0.08 analytic point estimate of 23.8% (95%
Escribè-Agüir et al,8 2008 (Spain) CI, 18.7%-29.7%). Time period was a
8.25 mo gestation EPDS (⬎10) 669 (687) 43 (6.5) 71 (10.3)
Hall and Long,63 2007 (Canada) CES-D (⬎16) 98 (91) significant determinant of maternal de-
8.75 mo gestation 11 (11.2) 30 (33) 0.27 pression (Q = 22.156; P ⬍ .001), with
2.5 mo postpartum 21 (21.4) 16 (17.6) 0.21 higher rates reported during the 3- to
(continued) 6-month postpartum period (41.6%).
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 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS

Measurement method (rating scale,

Table. Characteristics of Studies Included in Meta-analysis (continued)
25.5%; 95% CI, 20.0%-31.9%; inter-
Depressed, No. (%) Correlation
view, 9.8%; 95% CI, 5.9%-15.8%) was Depression No. of Between
Source (Study Location) Measure Participants Men and
also a significant predictor of mater- and Time of Assessment (Cutoff ) (Women) a Men Women Womenb
nal depression rate (Q = 12.773; Onset of paternal depression at gestation 6-9 mo (continued)
P⬍.001). Study location (United States, Keeton et al,49 2008 (US) CES-D (⬎15) 140
29.6; 95% CI, 19.3%-42.5%; interna- 9.04 mo gestation 21 (15) 62 (44)
tional, 19.7%; 95% CI, 15.0%-25.4%) 1.3 mo postpartum 17 (12) 36 (26)
demonstrated a trend toward higher 4.57 mo postpartum 17 (12) 41 (29)
6.68 mo postpartum 18 (13) 36 (26)
rates in the United States (Q = 2.599;
12.81 mo postpartum 15 (11) 35 (25)
P =.107).
Leathers and Kelley,12 2000 (US) CES-D (⬎16) 124
The overall random-effects esti-
6.5 mo gestation 9 (7.3) 38 (30.6)
mate of maternal-paternal depressive 3.75 mo postpartum 8 (6.5) 14 (11.3)
symptom correlation was signifi- Morse et al,52 2000 (Australia) EPDS (⬎9)
cantly larger than 0 and moderate in 6.25 mo gestation 251 30 (12) 49 (19.5)
magnitude (r = 0.308; 95% CI, 0.228- 9 mo gestation 204 18 (8.7) 45 (21.1)
0.384). 1 mo postpartum 166 10 (6) 38 (21.6)
4 mo postpartum 151 9 (5.8) 23 (13.9)
Tests for Publication Bias Raskin et al,59 1990 (US) CES-D (⬎15) 86
Visual inspection of funnel plots (avail- 8.5 mo gestation 16 (18.6) 24 (28) 0.09
able from the authors) revealed no ob- 2 mo postpartum 18 (21) 18 (21) 0.05
vious evidence of publication bias. Sandberg,66 1986 (US) BDI (⬎9) 50
9.5 mo gestation 8 (16) 24 (48)
Quantitative evaluation of publication
0.25 mo postpartum 4 (8) 17 (34)
bias, as measured by the Egger inter-
Onset of paternal depression at postpartum ⬍3 mo
cept, was nonsignificant (P = .15). Fi- Ballard et al,19 1994 (UK)
nally, the Orwin fail-safe procedure, 1.5 mo postpartum EPDS (⬎12) 178 16 (9) 49 (27.5)
using a base rate of 3%,36 determined 6 mo postpartum EPDS (⬎12) 148 8 (5.4) 38 (25.7)
that 1444 unpublished studies at or be- 6 mo postpartum PAS 148 6 (4.1) 23 (15.5)
Carro et al,39 1993 (US)
low this level would be needed to bring 1 mo postpartum BDI (⬎9) 70 7 (10) 20 (29) 0.25
the overall meta-analytic estimate of Davé et al,61 2005 (UK) 48
prenatal and postpartum depression to 1.25 mo postpartum HADS (⬎7) 4 (8)
a nonsignificant difference from the EPDS (⬎12) 4 (8)
base rate. Edhborg et al,41 2005 (Sweden) EPDS (⬎9) 106
0.25 mo postpartum 3 (2.8) 22 (20.8)
Sensitivity Analyses 2 mo postpartum 1 (0.9) 10 (9.4)
Robustness of meta-analytic findings Edhborg,62 2008 (Sweden) EPDS (⬎10)
was examined by sequentially remov- 0.25 mo postpartum 132 (167) 4 (3) 40 (24) d
ing each study and reanalyzing the re- 2 mo postpartum 113 (155) 2 (1.8) 19 (12)
Ferketich and Mercer,42 CES-D (⬎15) 172
maining data set (producing a new 1995 (US)
analysis for each study removed). No 0.5 mo postpartum 36 (20.9)
study affected the meta-analytic esti- 1 mo postpartum 30 (17.4)
mate more than 0.5%. Removing stud- 4 mo postpartum 25 (14.5)
ies with quality ratings in the lowest 8 mo postpartum 28 (16.3)
33% decreased the meta-analytic esti- Gao et al,46 2009 (China)
1.5 mo postpartum EPDS (⬎12) 130 14 (10.8) 18 (13.8) 0.37
mate of paternal depression by only
Goodman,47 2008 (US)
0.6% (from 10.4% to 9.8%). The pat- 2.5 mo postpartum EPDS (⬎9) 128 17 (13.3) 36 (28) 0.34
tern of differences across time peri- Greenhalgh et al,48 2000 (UK) EPDS (⬎12)
ods, measurement methods, and study 0.25 mo postpartum 78 5 (6.4)
locations remained essentially un- 1.5 mo postpartum 64 4 (6.3)
changed in direction and magnitude. Hjelmstedt and Collins,13
2008 (Sweden) e
2 mo postpartum EPDS (⬎9) 53 4 (7.5)
COMMENT
Lane et al,50 1997 (Ireland) EPDS (⬎12)
In this meta-analysis of paternal pre- 0.1 mo postpartum 175 (289) 6 (3) 33 (11.4)
natal and postpartum depression and 1.5 mo postpartum 175 (224) 2 (1.2) 24 (10.7)
its correlation with maternal depres- (continued)

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 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS

sion, wide variation was observed in re-

Table. Characteristics of Studies Included in Meta-analysis (continued)
ported rates of depression for fathers
Depressed, No. (%) Correlation
Depression No. of Between and mothers. The overall meta-
Source (Study Location) Measure Participants Men and
and Time of Assessment (Cutoff ) (Women) a Men Women Womenb
analytic rate of paternal depression be-
Onset of paternal depression at postpartum ⬍3 mo (continued) tween the first trimester and 1 year
Madsen and Juhl,15 postpartum was 10.4%. Since recent na-
2007 (Denmark)
1.5 mo postpartum EPDS (⬎9) 542 27 (5) tional data on base rates of depression
1.5 mo postpartum GMDS (⬎12) 529 18 (3.4) in men place the 12-month preva-
Matthey et al,64 2001 (Australia) lence at 4.8%, 70 this suggests that
1.6 mo postpartum DIS 208 (230) 6 (2.9) 24 (10.4)
paternal prenatal and postpartum de-
Mezulis et al,65 2004 (US) CES-D (⬎15) 350 0.12 f
pression represents a significant pub-
1 mo postpartum 55 (15.6) 41 (11.6)
4 mo postpartum 47 (13.3) 31 (8.8)
lic health concern. It must be noted that
12 mo postpartum 36 (10.2) 21 (5.9) considerable variability was observed
Pinheiro et al,54 2006 (Brazil) in reported rates of paternal depres-
2.25 mo postpartum BDI (⬎9) 386 46 (11.9) 91 (23.6) 0.52 g sion. Although timing of measurement,
Skari et al,56 2002 (Norway) GHQ (⬎1) h study location, and measurement
0.25 mo postpartum 115 (126) 2 (1.7) 7 (5.6) method were significant predictors, they
1.5 mo postpartum 103 (109) 2 (1.9) 1 (0.9)
accounted for only a small amount of
6 mo postpartum 84 (91) 1 (1.2) 2 (2.2)
0.25 mo postpartum GHQ (⬎5) i 115 (124) 13 (11.3) 46 (37.1)
overall heterogeneity. In terms of tim-
1.5 mo postpartum 102 (108) 11 (10.8) 23 (21.3) ing, fathers experienced the highest
6 mo postpartum 84 (91) 9 (10.7) 17 (18.7) rates of depression 3 to 6 months post-
Soliday et al,57 1999 (US) partum, although the small number of
0.79 mo postpartum CES-D (⬎16) 51 13 (25.5) 20 (39.2) 0.29 studies measuring paternal depres-
Thorpe et al,68 1992 (UK/Greece)
1 mo postpartum EPDS (⬎12) 267 (281) 2 (0.7) 35 (12.5)
sion during this period suggests cau-
Wang and Chen,58 tious interpretation. Differences were
2006 (Taiwan) also observed across study locations,
1.5 mo postpartum BDI (⬎9) 83 26 (31.3) 33 (39.8)
with higher rates of prenatal and post-
Onset of paternal depression at postpartum 3-6 mo
Bielawska-Batorowicz partum depression reported in the
and Kossakowska- United States (14.1% vs 8.2% interna-
Petrycka,38 2006 (Poland)
4.5 mo postpartum EPDS (⬎12) 80 22 (27.5) 25 (31.2) 0.76 tionally). Questionnaire methods of
Dudley et al,40 2001 (Australia) e case identification produced some-
3.9 mo postpartum EPDS (⬎10) 93 (158) 11 (11.8) 75 (47.5) d 0.33
what higher rates than did interview
GHQ (⬎4) 93 43 (46.2) 0.27
BDI (⬎9) 92 16 (17.4) 0.29
methods, although this should be in-
Smart and Hiscock,67
terpreted cautiously because of the
2007 (Australia) e small number of studies that used in-
3.75 mo postpartum EPDS (⬎9) 59 (71) 18 (30) 32 (45) j
terviews. Surprisingly, sample risk sta-
4.5 mo postpartum 53 (59) 10 (19) 9 (15)
tus was not a determinant of depres-
Onset of paternal depression at postpartum ⬎6 mo
Bronte-Tinkew et al,16 2007 (US) sion rates.
12 mo postpartum CIDI-SF 2137 115 (5.4) 143 (6.7) Maternal depression demonstrated
Leathers et al,51 1997 (US) considerable heterogeneity. This var-
6 mo postpartum CES-D (⬎15) 55 10 (18) 17 (31)
Paulson et al,10 2006 (US) ied by time period, with a peak rate of
9 mo postpartum CES-D (⬎9) 5089 509 (10) 712 (14) 41.6% in the 3- to 6-month postpar-
Abbreviations: BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; CES-D, Center of Epidemiologic Studies tum period, and by measurement
Depression Scale; CIDI-SF, Composite International Diagnostic Interview Short Form; DIS, Diagnostic Interview Sched-
ule; EPDS, Edinburgh Postnatal Depression Inventory; GHQ, General Health Questionnaire; GMDS, Gotland Male De- method (higher rates with rating
pression Scale; HADS, Hospital Anxiety Depression Scale; MHI-5, Mental Health Index of the Short Form–36 health sur- scales). Our random-effects estimate is
vey; PAS, Psychiatric Assessment Schedule; SADS, Schedule for Affective Disorders and Schizophrenia.
a Numbers in parentheses represent the number of women who participated at each time point. If a number in parenthe- somewhat larger than that of some re-
ses does not appear in this column and a percentage of depressed women is reported in the table, the number of female
participants is the same as the number of male participants. ports,1,2 with the variability in rates
b All correlations are Pearson r correlation coefficients unless otherwise noted.
c Fathers were assessed for depression using the BDI (⬎16 from time 1 through time 4) and the GHQ (⬎7 at time 1 and being clearly observable.
time 4 only). Mothers were assessed using the BDI (⬎16 at time 1, time 3, and time 4), EPDS (⬎12 at time 2 only), and In both men and women, the poten-
GHQ (⬎7 at time 1 and time 4 only).
d Percentage of depressed women based on EPDS greater than 9. tial causes of unexplained heteroge-
e The studies by Hjelmstedt and Collins13 (child conceived through assisted reproductive technology), Dudley et al,40 and
Smart and Hiscock67 (infant crying, sleeping, or eating problems in both) were considered to include high-risk individuals.
neity are varied. Although interview vs
f Point biserial. self-report questionnaire methods were
g Spearman correlation.
h A GHQ depression subscale case score greater than 1 indicates clinically important depression. compared, there were too many differ-
i A GHQ total case score greater than 5 indicates clinically important psychological distress.
j Percentages of depressed women based on EPDS greater than 12.
ent questionnaires and interviews to
conduct an instrument-by-instru-
1966 JAMA, May 19, 2010—Vol 303, No. 19 (Reprinted) ©2010 American Medical Association. All rights reserved.

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 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS

ment moderator analysis. Sample loca-

Figure 2. Prevalence of Paternal Birth-Related Depression From Gestation to 1 Year
tion and undetermined sample charac- Postpartum
teristics may also contribute to
heterogeneity. One possible source of Sample Effect Size
heterogeneity is the liberal inclusion of Study Size, No. (95% CI)
Gestation: first and second trimester
cases that can be classified as minor de- Areias et al,17 1996 42 0.05 (0.01-0.17)
pression, a category that includes in- Condon et al,6 2004 312 0.18 (0.14-0.23)
14
Fawcett and York, 1986 23 0.04 (0.01-0.25)
dividuals with depressive symptoms Field et al,43 2006 156 0.32 (0.25-0.40)
and impairment who do not meet strict 44
Fletcher et al, 2008 307 0.16 (0.12-0.20)
Frost,45 1996 527 0.14 (0.12-0.17)
criteria, either by severity, number, or Matthey et al,20 2000 152 0.05 (0.03-0.10)
duration of symptoms, for major de- Ramchandani et al,55 2008 10 975 0.04 (0.04-0.04)
van den Berg et al,7 2009 3083 0.12 (0.11-0.13)
pressive disorder.71 Few of the studies
reported herein explicitly described mi- Overall 0.11 (0.06-0.18)

nor depression, but the use of rating Gestation: third trimester

Atkinson and Rickel,37 1984 78 0.13 (0.07-0.22)
scale cutoff scores suggests that strict Bourne,60 2006 120 0.14 (0.09-0.22)
diagnostic criteria for major depres- Escribè-Agüir et al,8 2008 669 0.06 (0.05-0.09)
Hall and Long,63 2007 98 0.11 (0.06-0.19)
sive disorder were not used to identify Keeton et al,49 2008 152 0.14 (0.09-0.20)
cases. This interpretation is also con- Leathers and Kelley,51 2000 124 0.08 (0.04-0.14)
Morse et al,52 2000 251 0.12 (0.08-0.17)
sistent with the lower rates of identifi- Raskin et al,59 1990 86 0.19 (0.12-0.28)
cation observed in studies using struc- Sandberg,66 1986 50 0.16 (0.08-0.29)

tured interviews, a method that is Overall 0.12 (0.09-0.15)

typically more conservative in making Postpartum: birth to 3 mo
a clinical diagnosis. Ballard et al,19 1994 178 0.09 (0.09-0.14)
Carro et al,39 1993 70 0.10 (0.05-0.20)
Another area of focus for this meta- Davé et al,61 2005 48 0.08 (0.03-0.20)
analysis was the correlation between Edhborg et al,41 2005 106 0.03 (0.01-0.08)
Edhborg,62 2008 132 0.03 (0.01-0.08)
maternal and paternal depressive symp- Ferketich and Mercer,42 1995 172 0.21 (0.15-0.28)
toms. Examining this effect in the con- Gao et al,46 2009 130 0.11 (0.06-0.17)
Goodman,47 2008 128 0.13 (0.08-0.20)
text of paternal prenatal and postpar- Greenhalgh et al,48 2000 78 0.06 (0.03-0.14)
tum depression is important, as paternal Hjelmstedt and Collins,13 2008 89 0.04 (0.02-0.11)
Lane et al,50 1997 175 0.03 (0.01-0.07)
depression has been examined almost Madsen and Juhl,15 2007 529 0.03 (0.02-0.05)
exclusively in the context of fathers Matthey et al,64 2001 208 0.03 (0.01-0.06)
Mezulis et al,65 2004 350 0.16 (0.12-0.20)
paired with index mothers or chil- Pinheiro et al,54 2006 386 0.02 (0.00-0.07)
dren. Moreover, an extant meta- Skari et al,56 2002 113 0.02 (0.00-0.07)
Soliday et al,57 1999 51 0.26 (0.15-0.39)
analysis of maternal postpartum de- Thorpe et al,68 1992 267 0.01 (0.00-0.03)
pression suggests that marital Wang and Chen,58 2006 83 0.31 (0.22-0.42)

satisfaction, a close correlate of depres- Overall 0.08 (0.05-0.11)

sion, is among the strongest predic- Postpartum: 3 to 6 mo
tors of maternal depression.72 In our Bielawska-Batorowicz and 80 0.28 (0.19-0.38)
Kossakowska-Petrycka,38 2006
meta-analysis, 12 of the 14 correla- Dudley et al,40 2001 92 0.17 (0.11-0.27)
tions were significant (meta-analytic es- Smart and Hiscock,67 2007 59 0.34 (0.23-0.48)

timate, 0.308), a moderate association Overall 0.26 (0.17-0.36)

by most standards. Although other au- Postpartum: 6 to 12 mo
thors have suggested that maternal de- Bronte-Tinkew et al,16 2007 2137 0.05 (0.05-0.06)
Leathers et al,51 1997 55 0.16 (0.09-0.29)
pression may play some causal role in Paulson et al,10 2006 5089 0.10 (0.09-0.11)
paternal depression,5,11,40 none of the
studies included in this meta-analysis Overall 0.09 (0.05-0.15)

suggest direction of causal influence.
Studies that speak to direction of effect
are of great interest, particularly for their
implications for screening and preven-
tion, but strong evidence of this is not
yet available.
Our study has several limitations.
First, because studies used variable
methods of measuring and reporting de-
©2010 American Medical Association. All rights reserved.
Overall across all periods 0.10 (0.08-0.13)
Test for heterogeneity: I 2 = 94.91; P<.001
0.00 0.30 0.60
Event Rate (95% CI)
Overall effects were calculated through random-effects model estimates, with separate calculations for overall
effects within each period and across all periods. Effect sizes were calculated via a logit transformation of rates
(number of reported cases divided by the sample size), which were back-transformed to proportions after es-
timates and standard errors were computed. Studies are stratified by period of assessment. For studies that
assessed depression at multiple time points, only the earliest estimate is reported. Data marker size corre-
sponds to study sample size.
(Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1967

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 PRENATAL AND POSTPARTUM DEPRESSION IN FATHERS
pression in different time periods, time
frame–specific prevalence cannot be
clearly established, limiting interpre-
tation to the rate of depression ob-
served at that point in time. Also, since
point estimates are drawn from a pool
of heterogeneous studies, many of
which did not use strong population-
based sampling methods, there is a po-
tential of bias in our results from stud-
ies’ methodological weaknesses. These
may not have been adequately ac-
counted for by our simplified method
of quality rating. The method of iden-
tifying depressed cases was highly vari-
able across studies, thereby limiting the
specificity of our primary outcome.
However, this variability in case iden-
tification accurately reflects inconsis-
tencies in both applied and basic re-
search into prenatal and postpartum
depression. 5 Removing relatively
weaker studies in sensitivity analysis left
effects essentially unchanged. We did
not find substantial evidence of publi-
cation bias in this area, and fail-safe
analysis suggested that our findings are
robust to unpublished null findings.
With these limitations in mind, this
meta-analysis allows us to draw sev-
eral conclusions regarding paternal
prenatal and postpartum depression.
First, a significant number of expect-
ing and new fathers experience
depression during this period. Sec-
ond, expecting and new fathers in the
United States experience depression at
marginally higher rates than do
fathers internationally, a finding that
bears further investigation vis-à-vis
varying social norms and postpartum
work practices cross-nationally.
Third, there is a moderate correlation
between depression in fathers and
mothers. There are many implications
of these findings. The observation that
expecting and new fathers dispropor-
tionately experience depression sug-
gests that more efforts should be
made to improve screening and refer-
ral, particularly in light of the mount-
ing evidence that early paternal
depression may have substantial emo-
tional, behavioral, and developmental
effects on children.10,55 The correla-
1968 JAMA, May 19, 2010—Vol 303, No. 19 (Reprinted)
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tion between paternal and maternal
depression also suggests a screening
rubric 73 —depression in one parent
should prompt clinical attention to
the other. Likewise, prevention and
intervention efforts for depression in
parents might be focused on the
couple and family rather than the
individual.
Future research in this area should
focus on parents together to examine
the onset and joint course of depres-
sion in new parents. This may in-
crease our capacity for early identifi-
cation of parental depression, add
leverage for prevention and treat-
ment, and increase the understanding
of how parental depression conveys risk
to infants and young children.
Author Contributions: Dr Paulson had full access to
all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data
analysis.
Study concept and design: Paulson.
Acquisition of data: Paulson, Bazemore.
Analysis and interpretation of data: Paulson, Bazemore.
Drafting of the manuscript: Paulson, Bazemore.
Critical revision of the manuscript for important in-
tellectual content: Paulson, Bazemore.
Statistical analysis: Paulson, Bazemore.
Administrative, technical, or material support: Paulson,
Bazemore.
Study supervision: Paulson.
Financial Disclosures: None reported.
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